Neuropelveology for Endometriosis Management: A Systematic Review and Multilevel Meta-Analysis

Abstract

Background: Despite the availability of treatments such as surgery and hormonal therapy, women with endometriosis often endure chronic problems. This review aims to evaluate the effectiveness and safety of neuropelveology. Methods: In a systematic review with a meta-analysis, we searched three electronic databases: MEDLINE (PubMed), Scopus, Embase, and Web of Science (WOS). The search was conducted in January 2024 with no date or language restrictions using a carefully curated set of keywords. We conducted a comprehensive review, including all observational and clinical trials reporting data on neuropelveology approaches in the management of endometriosis, irrespective of geographical location. The studies included in our review were required to be published in peer-reviewed journals and be available in any language, with at least an abstract in English. The data of all included studies were summarized in excel (version 19) and were analyzed by Comprehensive Meta-analysis v3.3 (Biostat) and STATA (version 17). A multilevel meta-analysis was performed on studies with two arms (intervention and control) to evaluate the efficacy of neuropelveology in managing women with endometriosis. Results: After screening 476 records, 30 studies, published from 1952 to 2021, were included in this review, each employing various methodologies. The studies were divided into the following three categories: (a) efficacy of neurectomy or nerve resection (n = 20), (b) efficacy of neurolysis (nerve blocks) (n = 4), and (c) efficacy of neuromodulation (n = 6) in the management of endometriosis. Among the studies evaluating the efficacy of neurectomy or nerve resection, 10 studies (with 18 group comparisons) were included in the random-effects meta-analysis. Treatment success (not occurrence of pain) was higher with neurectomy vs. controls (RR = 0.497, 95% CI = 0.236 to 1.04, p = 0.06 (for experimental studies) and RR = 0.248, 95% CI = 0.14 to 0.43, p < 0.001 (for observational studies)), representing a 50% and 75.2% risk reduction in the recurrence of pain in experimental and observational studies, respectively. Similarly, neurolysis, particularly superior hypogastric plexus blocks and uterine nerve ethanol neurolysis, demonstrated encouraging outcomes in pain reduction and an improved quality of life for women with endometriosis. The efficacy of neuromodulation in managing endometriosis symptoms appears promising but requires further investigation. Conclusions: In conclusion, neuropelveology approaches, such as neurectomy, neurolysis, and neuromodulation, offer significant potential for pain reduction in endometriosis patients, albeit with risks of complications and high recurrence rates, necessitating careful patient selection and long-term monitoring.

Keywords: endometriosis; nerve; neuropelveology; pelvic pain.

Figure 1

The process of screening and selecting relevant studies.

Figure 2

Forest plot of treatment success comparing conservative surgery with or without neurectomy. The risk ratio and 95% confidence interval are plotted for each study. The pooled risk ratio (diamond apex) and 95% confidence interval (diamond width) were calculated using a random effects model. A pooled risk ratio >1 suggests a higher risk with pain recurrence. A pooled risk ratio < 1 suggests a lower risk with pain recurrence. Random effects risk ratio: neurectomy vs. controls (RR = 0.497, 95% CI = 0.236 to 1.04, p = 0.06 (for experimental studies) and RR = 0.248, 95% CI = 0.14 to 0.43, p <0.001 (for observational studies)). Box size represents study weighting. Diamond represents overall effect size and 95% CIs. CS = conservative surgery [32,33,34,35,41,42,43,44,53,57].

Figure 3

Distribution of true effects size based on experimental studies.

Figure 4

Funnel plot shows there is a publication bias.